Kaplan NCLEX Sample Test 2 Exam Questions With Correct answers
The nurse in the pediatric clinic performs a well-child assessment on a 15-month-old. The child's mother tells the nurse that she is very excited becaus
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Kaplan NCLEX Sample Test 2 Exam Questions With Correct answers
The nurse in the pediatric clinic performs a well-child assessment on a 15-month-old. The child's mother tells the nurse that she is very excited because her mother is visiting. The grandmother rarely visits, and the child's mother is pleased that grandmother and grandchild will spend time together. Which of the following responses by the nurse is MOST important?
1. "Your toddler may be fearful when left alone with her grandmother."
2. "How long is your mother staying?"
3. "Does your mother take any medication?"
4. "I'm sure your mother will enjoy her grandchild."
Strategy: "MOST important" indicates priority.
1) toddlers display less fear of strangers as long as parents are present; when left alone, the toddler may be fearful or anxious; appropriate information for the nurse to relate to the mother; psychosocial need
2) not the most important question
3) CORRECT— because toddlers explore by putting things in their mouths, parents should be aware of all potentially toxic substances in the home; parents should be aware if visitors in the home are taking medication, which should not be left in purses or suitcases lying around
4) safety takes priority
The nurse cares for client diagnosed in stage I chronic renal failure. During the nursing assessment, the nurse expects the client to state which of the following?
1. "I don't seem to urinate as much as I used to."
2. "I seem to have more swelling in my feet and ankles."
3. "I urinate more at night."
4. "The doctor told me I need dialysis."
Strategy: Think about what the client's words mean.
1) oliguria occurs during stage II (renal insufficiency)
2) occurs during stage II
3) CORRECT— stage I is diminished renal reserve; renal function is reduced but healthier kidney is able to compensate; since kidney not as able to concentrate urine, client has polyuria and nocturia
4) required in stage III (end-stage renal disease)
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The nurse cares for a client diagnosed with hypertension and type 1 diabetes mellitus. The client complains to the nurse that the physician wants the client to discontinue taking verapamil (Calan) 80 mg PO tid and begin taking captopril (Capoten) 50 mg PO tid. The client states, "It took a long time to find a medication that controls my blood pressure with minimal side effects, and I do not want to go through that again." Which of the following responses by the nurse is BEST?
1. "How many different antihypertensives did you try?"
2. "Captopril is the best drug for preventing or slowing down the destruction of your kidneys."
3. "Your physician is a specialist in this area and feels you need to change."
4. "Why not give it a try?"
Strategy: "BEST" indicates discrimination is required to answer the question.
1) focus on the here and now; not relevant how many different drugs the client tried
2) CORRECT— Capoten dilates the efferent arterioles, resulting in lowering the glomerular pressure; verapamil dilates the afferent arterioles, increasing the pressure
3) does not give the client a reason why the physician wants to change the medication
4) answer does not give the client any information
The home care nurse visits a client receiving levothyroxine (Synthroid) 75 mcg OD. The client tells the nurse that he has been experiencing insomnia the last couple of weeks. Which of the following responses by the nurse is MOST appropriate?
1. "The physician may have to decrease the dose of medication."
2. "Tell me about your bedtime routine."
3. "When do you take the medication?"
4. "Take a warm bath before going to bed."
Strategy: "MOST appropriate" indicates discrimination may be required to answer the question.
1) should assess before implementing
2) assessment; more important to determine when client is taking the medication
3) CORRECT— should take medication before breakfast to prevent insomnia
4) assumes that medication is not the cause of the insomnia
The nurse cares for clients on the neurological unit. After receiving report, which of the following clients should the nurse see FIRST?
1. A client who is non-responsive with intermittent limb movement.
2. A client whose muscle tone of all four limbs is flaccid.
3. The client who is non-responsive but follows the staff with his eyes.
4. The client who immediately withdrawals from painful stimuli.
Strategy: Determine the most unstable client.
1) limb movement indicates brain injury is not severe
2) CORRECT— flaccidity most indicative of serious irreversible impairment
3) tracking with the eyes indicates client less impaired than client with flaccid muscles
4) indicates a higher level of consciousness, according to Glasgow Coma Scale
While sitting at the front desk completing an assessment sheet, a new graduate nurse asks the nursing assistant to perform a finger stick blood sugar for the assigned client. The nursing assistant responds, "Why can't you do it?" Which of the following responses by the nurse is BEST?
1. "Please page me when you have completed the task."
2. "It is important that the blood sugar be completed now."
3. "Why did you ask that?"
4. "If you don't have time, I will ask someone else to do it."
Strategy: "BEST" indicates discrimination is required to answer the question.
1) CORRECT— performing a finger stick is within the scope of practice of the nursing assistant and the task should be carried out as delegated
2) nurse not required to explain assignment
3) nontherapeutic; leads to further discussion, which is not appropriate
4) example of reverse delegation, lower person on hierarchy delegates to person higher on the hierarchy
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